And Solotaroff, an Oregon Health and Science University staff physician and researcher, takes a breath and knows that even this is part of her education.

In August, Solotaroff took a second job. In addition to spending two days each week seeing patients and studying the chronically ill at OHSU, Solotaroff has become the medical director at Central City Concern, a downtown-based social-service agency that provides medical, housing and employment assistance to a predominantly homeless population, including many who are chemically addicted.

Solotaroff's position is part of a new joint venture between OHSU and Central City Concern that includes requiring all OHSU internal medicine residents to spend at least one month volunteering at the Old Town medical clinic Solotaroff oversees.

The concept is simple, according to Ted Amann, director of health care and improvement at Central City Concern. The agency gets residents to help treat patients who are otherwise mostly treated by nurses and naturopaths. The residents get an education in real-world medicine from those nurses and naturopaths that often bears little resemblance to what they learned in the classroom or around the hospital.

Clinic is its own classroom

Central City Concern's Old Town Clinic treated 4,195 people in 2005. Its Hooper Detox Center and its roving response van, which picks up the publicly inebriated, handled more than 13,000 encounters last year.

OHSU residents are required to spend at least a month in a rotation that includes a half-day at Hooper and a night riding along in the Chiers van.

The residents learn how to detox alcoholics and recognize schizophrenia. They are given an education, Solotaroff says, in all the bits and pieces of sadly lived lives, and how all those bits and pieces affect physical health.

'We expect a lot of our patients to be able to take care of their diabetes, asthma and hypertension,' Solotaroff says. 'And in the medical world we frequently don't connect that to other illnesses like mental illness or addiction. And particularly we don't connect that to their social situations - poverty, homelessness and criminality.'

Solotaroff has learned quickly. And she's not shy about passing on what she's learned. 'I tell residents, housing is your sixth vital sign here,' she says. 'You need to ask about it with every patient here.'

Bill Ward, a second-year resident in OHSU's internal medical program, says that until his rotation at the Old Town Clinic he had little understanding of the different ways different drugs reveal themselves through symptoms.

Ward says he has learned that withdrawal from alcohol produces more agitation and hallucinations and that heroin withdrawal can produce upset stomach, tremors, headaches and jitteriness. All lessons that Ward says will serve him well when he's back treating patients with insurance at OHSU.

Meghan Liel, a first-year resident at OHSU who served a one-month rotation at the Old Town Clinic in August, says the contrast between what's available at Central City Concern's facility and what's available at hospitals such as OHSU is a lesson in itself.

At the Old Town Clinic, Liel says, 'You figure out what tests you really need to order when you can't order everything you want.' A similar situation occurs, Liel says, when she must choose a medication from the limited supply at the Old Town Clinic rather than simply write a prescription for a pharmacy to fill.

That is a lesson Liel intends to keep in mind as she treats patients at OHSU. 'It's always important to think about what you really need and what your resources are,' she says. 'Our health care system is not unlimited, no matter what those of us with insurance would like to think.'

At this point, the joint venture appears to favor OHSU. Solotaroff, the residents and Amann all agree that with one-month rotations, residents are doing a lot more learning than treating so far. But long-term that is expected to change.

Next year, Central City Concern will pick up Solotaroff's full salary, now split between the agency and OHSU. But eventually, Amann says, OHSU residents will visit the clinic for two-day-a-week rotations that might last as long as six months. The focus then will be on treating, not just learning.

Also, Amann says, Central City Concern has long wanted to find a way to perform studies that could validate what its workers have been learning on the job.

For example, Amann says, staff at the clinic have learned over the years that most addicts must stabilize the rest of their lives before they can address health issues such as diabetes, hypertension and asthma.

'We've seen how our services work,' Amann says. 'We've seen people come off the streets, they get housing, they get acute health care, and once those basics are taken care of they are able to address their chronic health care issues.'

New research avenues

The association with OHSU should allow the agency to tap into OHSU's research potential and get money for clinical studies.

Solotaroff also recognizes the potential for research stemming from the new partnership. She sees a slew of topics on the relationship between homelessness, addiction and health that she would like to systematically study at the Old Town Clinic.

For now, Solotaroff is content to settle into what she calls her dream job. Just watching the clinic's patients trying to overcome addictions has changed her outlook on medicine, Solotaroff says.

'People move through a number of cycles of relapse and recovery,' Solotaroff says. 'Doctors don't like that. Doctors hate that - backtracking.'

But recently, Solotaroff says, one of the Old Town Clinic's nurses had a talk with her. 'She said one of the most profound things about medical care I've ever heard. She said, 'When I'm working with these people I feel my job is just to keep them alive.' Her point was that at some point that cycle will break, people will go into more prolonged periods of being healthy. It restructured the way I think about medicine. Because you never give up.'

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